Avir At Rose Trail

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

review of the facility's wandering and elopement policy dated March 2019 indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials.when the resident returns to the facility the director of nursing services or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative.complete and file an incident report; and document relevant information in the resident's electronic health record. The Administrator was notified on 8/14/25 at 12:15 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/14/25 at 12:18 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: Implementing one to one supervision for Resident #1 until she could be transferred to a memory care unit. In-servicing all staff regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors. This was verified by

the in-service sheets showing all staff signed off their attendance to the aforementioned in-services.

Implemented a new policy requiring the checking of doors every 30 minutes and recording this task in a logbook. This is verified by the in-service sheets signed by all staff and the policy entitled Inservice Door Alarms/Checks. Transferred Resident #1 to a higher level of care at a neighboring memory care unit on 8/11/2025. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by:

Record review of the Resident #1's monitoring log dated 8/10/25 indicated Resident #1 was on one-to-one monitoring beginning 8/10/25 at 7:00 p.m. and continued until 8/11/25 at 11:00 a.m when she was transferred to a memory care unit at another facility. Record review of in-services dated 8/11/25 indicated all active staff were in-serviced regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors and the new door monitoring log policy. Staff interviewed (LVN A, LVN B, LVN C, RN D, RN E, CNA F, CNA G, CNA H, and CNA J) on 8/13/25 between 11:00 a.m. and 4:07 p.m. were able to articulate the content of the new door log book policy, and what to do in the event of an elopement. Staff interviewed said that they would notify the charge nurse and attempt to redirect the resident if they saw someone attempting to elope from the facility.

Investigator ensured all exits armed with Wanderguard system were in working order by approaching each exit with a Wanderguard device and hearing the alarm sound. The noncompliance was identified as PNC IJ.

The noncompliance began on 8/10/2025 and ended on 8/11/2025. The facility had corrected the noncompliance before the survey began.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter Tyler, TX 75701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

decannulation. During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy. The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency. The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy. During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter. The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required. The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used. The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy. Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times.

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